Coding Cases
Exam 1
ICD-10-CM
Q: Patient admitted with sepsis due to pneumonia, complicated by acute renal failure.
A: A41.9, J18.9, N17.9
Rationale: Sepsis is principal; pneumonia is underlying infection; renal failure is
complication.
Q: Type 2 diabetes mellitus with diabetic neuropathy.
A: E11.40
Rationale: Combination code captures both condition and complication.
PCS
Q: Laparoscopic cholecystectomy.
A: 0FT44ZZ
Rationale: Entire gallbladder removed via endoscopic approach.
Q: Lumbar spinal fusion with autologous bone graft.
A: 0SG00ZZ
Rationale: Fusion procedure with autologous tissue substitute.
CPT
Q: Colonoscopy with biopsy.
A: 45380
Rationale: Biopsy is highest-level service performed.
Q: Cardiac stress test with supervision, interpretation, and report.
A: 93015
Rationale: Includes all components performed by physician.
Q: Patient admitted with sepsis due to pneumonia, complicated by acute renal failure.
A: A41.9, J18.9, N17.9
Rationale: Sepsis is principal; pneumonia is underlying infection; renal failure is
complication.
Q: Type 2 diabetes mellitus with diabetic neuropathy.
A: E11.40
Rationale: Combination code captures both condition and complication.
PCS
Q: Laparoscopic cholecystectomy.
, A: 0FT44ZZ
Rationale: Entire gallbladder removed via endoscopic approach.
Q: Lumbar spinal fusion with autologous bone graft.
A: 0SG00ZZ
Rationale: Fusion procedure with autologous tissue substitute.
CPT
Q: Colonoscopy with biopsy.
A: 45380
Rationale: Biopsy is highest-level service performed.
Q: Cardiac stress test with supervision, interpretation, and report.
A: 93015
Rationale: Includes all components performed by physician.
Exam 2
ICD-10-CM
Q: Malignant neoplasm of head of pancreas.
A: C25.0
Rationale: Site-specific neoplasm coding.
Q: Pregnancy complicated by gestational diabetes, diet-controlled.
A: O24.410
Rationale: Gestational diabetes codes specify management method.
PCS
Q: Kidney transplant, open approach.
A: 0TY00Z0
Rationale: Transplant procedure requires donor organ specification.
Q: Endovascular repair of abdominal aortic aneurysm with stent graft.
A: 04V03DZ
Rationale: PCS requires device and approach detail.
CPT
Q: Emergency department visit, high severity.
A: 99285
Rationale: CPT distinguishes ED visit levels; 99285 is highest.
Q: CT abdomen with contrast.
A: 74177
Rationale: Specific CPT code for CT abdomen with contrast.
Q: Malignant neoplasm of head of pancreas.
A: C25.0